KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
HIMPUNAN MAHASISWA PRODI
PROGRAM STUDI D-III KEBIDANAN KEDIRI
TAHUN 2014/2015
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website :http://www.poltekkes-malang.ac.id

Format Asuhan Kebidanan Pada Ibu Nifas (PNC)

I. Pengkajian

Tanggal : Jam :

No. RM :

Nama : Nama Suami :

Umur : Umur :

Agama : Agama :

Pendidikan : Pendidikan :

Pekerjaan : Pekerjaan :

Alamat : Alamat :

Cara masuk :

Datang Sendiri Rujukan dari :

Diagnose :

A. DATA SUBYEKTIF
1. Keluhan utama :
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2. Riwayat menstruasi
 Usia manarche :
 Jumlah darah haid :
 HPHT :
 Keluhan saat haid :
 Lama haid :
 Flour albus :
 TP :
 Keluhan haid :

Disminorhoe Spoting Menorrhagia Premenstrual syndrome

Dll..............
3. Riwayat kehamilan,persalinan, dan nifas yang lalu.
G............................P.............................A.........................Hidup..............................

NO. Tgl, Tempat Umur Jenis Penolong Penyulit Anak Keadaan

Th partus kehamilan Kelamin persalinan JK/BB anak
partus sekarang

4. Riwayat kesehatan penyakit yang pernah diderita :

 Anemia
 Hipertensi
 Kardiovaskular
 TBC
 Diabetes
 Malaria
 IMS (Sphilis, GO, HIV/AIDS, dll)
 Lain-lain....
Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................
Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
Lain-lain
5. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
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6. Status perkawinan : ya/tidak
Kawin.............kali, kawin usia..............tahun, lama menikah....................tahun
7. Riwayat psiko sosial ekonomi
- Respon ibu dan keluarga terhadap kehamilan
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- Penggunaan alat kontrasepsi KB
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- Dukungan keluarga
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- Pengambilan keputusan dalam keluarga
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- Gizi yang dikonsumsi dan kebiasaan makan
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- Kebiasaan hidup sehat
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- Beban kerja sehari
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- Tempat dan penolong persalinan yang diinginkan
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- Penghasilan keluarga
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8. Riwayat KB dan rencana KB

Metode yang pernah dipakai : ......................................., Lama : ...................bulan/tahun
 Komplikasi dari KB : ..................................., Rencana KB selanjutnya:
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9. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS Endometritis
Polip serviks Kanker kandungan Operasi kandungan Perkosaan
DUB dll........................

10. Pola makan / minum/ eliminasi/ istirahat

- Pola minum : .................gelas/hari alkohol Jamu Kopi
- Pola eliminasi :
BAK.................cc/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK terakhir
jam :.........
BAB..................kali/hari, karakteristik: lembek/keras, BAB terakhir jam :.........................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................
- Dukungan keluarga : Suami Orang tua Mertua Keluarga lain

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang melebur
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
b. TFU : .............................., Kontraksi Uterus : Baik/lembek
Diastesis rectus abdomonis : +/-, ............................
Kandung kemih : Kosong/ penuh
Vulva Vagina : Lochea.................., Bau +/-
Luka Jalan lahir : Ruptur/Episiotomi, bengkak/tidak, bersih/kotor, luka
jahitan bertaut/tidak, basah/kering
Tanda-tanda Reeda (Red, Echimosis, Edema, Discharge, Aproximal)
Ekstremitas : Tromboflebitis (ada/tidak, berapa lama....................)
 4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................

C. ANALISIS / INTEPRETASI DATA

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 D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................

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Kediri,............................

Pembimbing Praktik Mahasiswa

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NIP. NIM.

NIP. NI

Dosen Pembimbing

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NIP.